档案资源开发2023年第37卷第5期《档案学研究》
病历档案数据标准化探索—以心内科临床诊断名称同义词表构建为例
Exploration on Data Standardization of Medical Records: Establishment of Synonym Table of Cardiology Clinical Diagnosis Terms as an Example
1 国家档案局档案科学技术研究所 北京 100050 2 北京协和医院 北京 100730
摘要
病历档案中临床诊断名称和ICD编码的准确性对医疗质量评价和医保支付至关重要。本文分析了影响临床诊断名称和ICD编码准确性的现实问题,提出了构建临床诊断名称同义词表这一解决方案。文章进一步介绍了临床诊断名称同义词表的编制方法,并从心内科入手,编制了心内科临床诊断名称同义词表,同时与多版本ICD编码进行了映射。文章提出的解决方案为提升病历档案数据质量,从源头上实现病历档案数据的标准化以及促进病历档案数据利用提供了一种工具。
关键词:病历档案数据标准化同义词表档案利用
Abstract
The accuracy of clinical diagnosis terms and ICD codes in medical records is significantly important to the evaluation of medical quality and medical insurance payment. In this paper the authors analyzed the situation and problems affecting the accuracy of clinical diagnosis terms and ICD codes and proposed to establish a synonym table of clinical diagnosis terms as a consequent solution. In this paper, the method for establishing a synonym table of clinical diagnosis terms was described, a synonym table of cardiology clinical diagnosis terms, which mapped with multiple ICD standards, was established. The synonym table could be used as a tool for enhancing the data quality of, realizing from the source the data standardization of, and boosting access to the medical records.
Key words: medical record; data; standardization; synonym table; archival access
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